Annual Report 2012/13

Transcription

1 Annual Report 2012/13

2 Commonwealth of Australia 2013 This work is copyright. It may be reproduced in whole or in part for study or training purposes, subject to the inclusion of an acknowledgement of the source. Address requests and inquiries concerning reproduction and rights for purposes other than those indicated above in writing to: Erica Hall Communications Coordinator Australian Commission on Safety and Quality in Health Care GPO Box 5480 Sydney NSW 2001 Or Suggested citation: Australian Commission on Safety and Quality in Health Care, Annual Report 2012/13. Sydney. ACSQHC, An online version of this report can be accessed at ISSN (Print) ISSN (Online) ABN

3 Letter of transmittal The Hon. Peter Dutton MP Minister for Health Parliament House Canberra ACT 2600 Dear Minister On behalf of the Board of the Australian Commission on Safety and Quality in Health Care (the Commission), I am pleased to submit our annual report for the financial year ending 30 June The report reflects the requirements of the National Health Reform Act 2011 and section 9 of the Commonwealth Authorities and Companies Act 1997 (CAC Act). The report and the audited financial statements were prepared in accordance with the Commonwealth Authorities and Companies Orders (Financial Statements for reporting periods ending on or after on or after 1 July 2011), made by the Finance Minister under the authority of section 48 of the CAC Act. This report was approved for presentation to you in accordance with a resolution of the Commission s Board on 18 September I commend this report to you as a record of our achievements and compliance. Yours sincerely Professor Villis Marshall AC Chair Australian Commission on Safety and Quality in Health Care 20 September 2013 I

4 Contents This annual report was prepared and submitted in accordance with parliamentary reporting and legislative requirements. It provides an overview of the Australian Commission on Safety and Quality in Health Care s operations and performance for the financial year ending 30 June Letter of transmittal I 1. Overview 1 About the Commission 2 Highlights 2012/13 4 Welcome from the Chair 6 Report from the CEO 8 2. Our work 11 Our work priorities 12 National safety and quality standards and accreditation 13 Supporting quality practice and clinical standards 20 Data set development 30 Publishing and reporting 33 Knowledge and leadership in safety and quality Assessment of safety and quality in health care 41 A systems-based approach to improving safety and quality 42 Consumers, patients, families and carers are at the centre of health care 43 Supporting consumers to get the right care 44 Measuring the safety and quality of care Corporate governance and accountability 45 Legislation and requirements 46 Strategic planning 46 Ministerial Directions 46 Commission Board 47 Committees 53 Internal governance arrangements 55 External scrutiny 56 Developments and significant events 57 Environmental performance and ecologically sustainable development 57 National Health Reform Act amendments 57 II

5 5. Our organisation 59 Organisational structure 60 People management 62 Staff profile 62 Non-salary benefits 63 Workplace health and safety 63 Learning and development 64 Disability strategy Financial statements 65 Independent auditor s report 66 Statement by the Directors, Chief Executive Officer and Chief Financial Officer 68 Statement of comprehensive income 69 Balance sheet 70 Statement of changes in equity 71 Cash flow statement 72 Schedule of commitments 73 Notes to and forming part of the Financial Statements for the period ended 30 June Appendices 99 Appendix A: Publications 100 Appendix B: Published articles 104 Appendix C: Engagement in research 105 Appendix D: Event sponsorship 112 Appendix E: External representations 113 Appendix F: Formal consultations 115 Appendix G: Freedom of Information summary 117 Appendix H: Compliance to ecologically sustainable development Indexes and references 119 Acronyms and abbreviations 120 Glossary 121 Index of tables 126 Compliance index 127 Index 129 References 138 III

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7 1 Overview About the Commission 2 Highlights 2012/13 4 Welcome from the Chair 6 Report from the CEO 8 1

8 1 Overview About the Commission The Australian Commission on Safety and Quality in Health Care (the Commission) commenced as an independent, statutory authority on 1 July The Australian, state and territory governments initially established the Commission in 2006 to lead and coordinate national improvements in safety and quality. The Commission s permanent status was confirmed with the assent of the National Health and Hospitals Network Act The Commission was subsequently included within the National Health Reform Act Our mission To lead and coordinate national improvements in the safety and quality of health care. Our vision A health system that is informed, supported and organised to deliver safe and high quality health care, which contributes to: better experiences for patients and consumers better health outcomes for the population improved productivity, and greater sustainability. Our role The Council of Australian Governments established the Commission to lead and coordinate national improvements in the safety and quality of health care. Our role is to provide health ministers with strategic advice on best practices to improve safety and quality in the health system. The Commission develops and supports national safety and clinical standards; formulates and implements national accreditation schemes; and develops national health-related data sets. We are also working on reducing unwarranted variations in practice and outcomes for individuals and populations, and undertaking nationally coordinated action to address healthcare associated infections and antimicrobial resistance. The National Health Reform Act 2011 specifies the Commission s roles and responsibilities as a permanent independent authority under the Commonwealth Authorities and Companies Act 1997 (CAC Act). For details of the Commission s specific functions under section 9 of the National Health Reform Act 2011 see page 12. 2

9 Overview 1 Our values The Commission values close, collaborative relationships with our partners from across the healthcare sector. These partners include consumers, healthcare providers, governments, and other healthcare organisations and agencies. The Commission and its people act with independence, transparency, fairness, respect, accuracy and accountability. We are committed to producing high-quality work, making ongoing improvements and enhancing a supportive work culture. Our accountability As a statutory authority of the Australian Government, the Commission is accountable to the Parliament and the Minister for Health, the Honourable Peter Dutton MP, for our performance in achieving the outcomes of our agreed work plan and priorities. The Honourable Tanya Plibersek MP was the Minister for Health and the Commission s responsible Minister during the 2012/13 reporting period. 3

10 1 Overview Highlights 2012/13 July 2012 The Commission and the National Mental Health Commission started a new project to look at the way in which national standards are used in mental health services. August The Commission began developing 10 Safety and Quality Improvement Guides to support implementation of the National Safety and Quality Health Service (NSQHS) Standards. The Commission and the Independent Hospital Pricing Authority began to look at options for incorporating safety and quality into the way Australian public hospital services are funded. September The Commission established the NSQHS Standards Accreditation Advice Centre. Since opening, the centre has provided advice on the NSQHS Standards, in particular on healthcare associated infection, patient identification and recognising and responding to clinical deterioration. The Commission s Clinical Care Standards program was established. The first three Clinical Care Standards will address Acute Coronary Syndrome, Stroke and Antimicrobial Stewardship. The Commission released the Health Literacy Stocktake Consultation Report, an overview of health literacy activities and initiatives across Australia. November The Commission and NPS MedicineWise launched the first Antibiotic Awareness Week with the Minister for Health. 2,083 box sets of the NSQHS Standards, Safety and Quality Improvement Guides and Accreditation Workbooks were distributed to hospitals and day procedure services across the country. 12 accrediting agencies received approval to assess health service organisations for compliance to the NSQHS Standards. 4

11 Overview 1 January The NSQHS Standards accreditation process commenced for hospitals and day procedure services nationally. March The Commission began visits to health service organisations undergoing accreditation to confirm their understanding and uptake of the NSQHS Standards. As of June 2013, intensive education programs had been delivered at over 60 sites. April The Commission Board appointed a new Chair, Professor Villis Marshall, and welcomed three new Directors. The Commission released an initial report to the Organisation of Economic Cooperation and Development (OECD) on medical practice variation in Australia. May The 100th health service was assessed for accreditation in accordance with NSQHS Standards. The Commission finalised development of the Australian Open Disclosure Framework. June 2013 Almost 2,500 people and organisations subscribed to On the Radar. The Commission released the updated Core, Hospital-based Outcome Indicators Toolkit. The toolkit enables jurisdictions and private hospital ownership groups to generate nationally referenced and risk-adjusted core indicators. 137 health service organisations were assessed for accreditation to the NSQHS Standards from 1 January to 30 June Of these, 44 health services achieved accreditation to the NSQHS Standards and 93 health service organisations were given additional time to finalise their accreditation process. 5

12 1 Overview Welcome from the Chair Professor Villis Marshall AC Lapses in the safety and quality of health care have enormous costs, in terms of the effects on people s lives and the financial costs for health service organisations. At least one in every seven dollars spent on hospital care is from injuries or illnesses acquired in hospitals. For example, it is estimated that hospital-acquired infections add a total of 850,000 bed days to Australian hospital stays each year. 1 While not all lapses can be prevented, a systemic improvement in the safety and quality of health care can improve patient outcomes, reduce costs and increase capacity. 2 All health systems irrespective of their structure or financing model face major challenges in ensuring the delivery of safe and high-quality care. The Australian Government aims to improve the long-term capacity, quality and safety of Australia s healthcare system. This will be achieved in part through the Commission s work. In 2012/13, the Commission made significant progress towards its vision for a health system that is better informed, supported and organised, and which delivers safe and high-quality care. Some highlights for 2012/13 included: NSQHS Standards This year, the Commission oversaw the implementation of National Safety and Quality Health Service (NSQHS) Standards and the national accreditation process. The Commission invested considerable resources to help health service organisations achieve accreditation, including producing implementation guides and workbooks, and establishing a dedicated Accreditation Advice Centre. Clinical Care Standards The Commission also started developing a set of Clinical Care Standards. Being developed in consultation with healthcare providers and consumers, the Clinical Care Standards aim to improve patient outcomes and experiences, and ensure health care is safe and appropriate. The Clinical Care Standards will also promote shared decision making between patients and clinicians. After a broad consultation process, the Commission selected acute coronary syndrome, stroke and antimicrobial stewardship as the first practice areas to be addressed. In 2013, the Commission began developing a set of Clinical Care Standards for each of these areas. 6

13 Overview 1 International and national collaborations In 2012/13, the Commission embarked on several collaborative projects with national and international organisations. One of these is a project with the Independent Hospital Pricing Authority (IHPA). The Commission and the IHPA have been working together to investigate options for including safety and quality in the pricing model for Australian public hospital services. The Commission is also coordinating Australia s participation in a medical practice variations study the Organisation for Economic Co-operation and Development (OECD) is undertaking. Australia is one of 13 countries involved in the study. The Board has welcomed three new members: Professor Phillip Della, the Honourable Verity Firth and Dr Shaun Larkin. They each bring a wealth of experience to the Board and I look forward to working with them over the next year. I would like to take this opportunity to thank the Standing Council on Health, Board members, the Commission s Executive Management team and staff members for their continued commitment to the Commission s vision. Their significant achievements are described in detail throughout this annual report. Acknowledgements In April 2013, the Board farewelled its longstanding Chair, Bill Beerworth. I would like to thank Mr Beerworth for his invaluable contributions to the Commission since his appointment in I would also like to thank Board Directors Veronica Casey and Richard Bowden, whose terms also ended in 2012/13. 7

14 1 Overview Report from the CEO Professor Debora Picone AM The end of 2012/13 marked the Commission s second anniversary as an independent statutory corporation. It was another busy and successful year, during which the Commission further developed its planning and governance frameworks, and expanded its work programs. Some key areas of work included: Strategic planning In February 2013, health ministers endorsed the Commission s first three-year rolling work plan, as mandated under the National Health Reform Act The Work Plan sets out the Commission s priorities and deliverables for the period. Implementation of the National Safety and Quality Health Service Standards From January 2013, accreditation to the NSQHS Standards began for hospitals and day procedure services. Health service organisations have been supportive of the NSQHS Standards and the accreditation process. Early reports indicate the NSQHS Standards have had a positive effect on safety and quality across acute health care. The success of the implementation of the NSQHS Standards can be attributed in part to the considerable support the Commission has provided to health service organisations of all sizes. The Commission produced implementation guides and resources, as well as monitoring and reporting tools, and provided accreditation advice, network coordination and mediation services. The successful implementation of the NSQHS Standards also depended on the partnership between the federal, state and territory health systems and the private sector. Everyone has been very committed to working towards improving patient safety. Reducing antimicrobial resistance The issue of antimicrobial resistance has continued to increase in profile. In November 2012, the Commission was involved in the first Australian Antibiotic Awareness Week. The event provided a significant opportunity to promote the appropriate use of antibiotics to healthcare providers and the community on a national scale. 8

15 Overview 1 In March 2013, the Australian Antimicrobial Resistance Prevention and Containment (AMRPC) Steering Group was established. The AMRPC Steering Group will provide governance and leadership on antimicrobial resistance, and oversee the development and implementation of a national framework for work related to antimicrobial resistance. Professor Jane Halton, the Secretary of the Department of Health and a Commission Board member, shares the role of Chair of the AMRPC Steering Group with the Secretary of the Department of Agriculture. Future work The Commission will continue to support the implementation of the NSQHS Standards and coordinate the Australian Health Services Safety and Quality Accreditation Scheme. The Commission will evaluate the impact of the NSQHS Standards in Acknowledgements In April 2013, Professor Villis Marshall AC was appointed as Chair of the Commission s Board. I would like to congratulate Professor Marshall on his appointment, and thank our inaugural Chair, Bill Beerworth, for his leadership during his tenure. I would also like to acknowledge and thank the Standing Council on Health, jurisdictional Chief Executives, the Department of Health and Ageing, the Commission s Board, Inter-Jurisdictional Committee and our many committee members for contributing their insight and expertise to the Commission s work. Finally, I would like to acknowledge the commitment of the Commission s staff members their hard work throughout the year is reflected in the achievements presented in this report. In all its work programs, the Commission will continue to ensure that consumers, patients, families and carers are at the centre of improvements in the safety and quality of health care. The Commission aims to ensure that its work is informed by the experience of consumers, and is relevant to them. The Commission will also seek to build on successful programs undertaken by states, territories, private hospital and primary care sectors, and consumer organisations. 9

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17 2 Our work Our work priorities 12 National safety and quality standards and accreditation 13 Supporting quality practice and clinical standards 20 Data set development 30 Publishing and reporting 33 Knowledge and leadership in safety and quality 36 11

18 2 Our work Our work priorities The Commission leads and coordinates improvements in the safety and quality of health care in Australia by identifying issues and policy directions, and recommending priority areas for action. Section 9 of the National Health Reform Act 2011 details the Commission s specific functions as: formulating standards, guidelines and indicators relating to healthcare safety and quality matters advising health ministers on national clinical standards promoting, supporting and encouraging the implementation of these standards, and related guidelines and indicators monitoring the implementation and impact of these standards promoting, supporting and encouraging the implementation of programs and initiatives relating to healthcare safety and quality matters formulating model national schemes that provide for the accreditation of organisations that provide healthcare services and relate to healthcare safety and quality matters collecting, analysing, interpreting and disseminating information relating to healthcare safety and quality matters, and publishing reports and papers relating to healthcare safety and quality matters. There were no changes to the National Health Reform Act 2011 or the Commission s legislative functions during the 2012/13 financial year. In line with these functions as well as those spelt out in the National Health Reform Agreement signed by the state, territory and Australian governments, and the work that health ministers identified for the Commission, including the Australian Safety and Quality Goals for Health Care the Commission set the following work priorities for 2012/13: 1. Develop and maintain national safety and clinical standards. 2. Formulate national accreditation schemes. 3. Develop a national dataset. 4. Undertake publishing and reporting. 5. Share knowledge and assume a leadership role on safety and quality in health care. The projects and deliverables for each of these priority areas are detailed in the following pages. 12

19 Our work 2 National safety and quality standards and accreditation At the request of health ministers, the Commission developed ten National Safety and Quality Health Service (NSQHS) Standards in collaboration with healthcare providers, consumers and governments. The health ministers endorsed these standards in The Commission is supporting the use of the NSQHS Standards by developing and promoting resources that facilitate their implementation. The Commission is providing national coordination of accreditation reforms for health system regulators, accrediting agencies and health services. This involves implementing accreditation reforms in line with the Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme. The Commission has started a new body of work to help mental health service providers apply safety and quality standards in mental healthcare settings. In addition, the Commission is developing national Clinical Care Standards to improve patient care outcomes. The Commission is progressing this for the priority areas identified in the Australian Safety and Quality Goals for Health Care to improve patient care. Finally, the Commission is finalising its commitment to the Australian Health Ministers Advisory Council (AHMAC) to develop national standards for clinical quality registries. Implementing the NSQHS Standards The aim of the NSQHS Standards accreditation process is to promote and support safe patient care and quality improvements across all care settings. The NSQHS Standards focus on areas where harm occurs to patients; where there are variations in practice; and where there is evidence that interventions make a difference to care. The NSQHS Standards provide a framework for health services to improve patient care, and to implement relevant safety and quality systems. The NSQHS Standards are integral for accrediting Australian hospitals and day procedure services, as they determine how, and against what standards, a health service s performance will be assessed. The ten standards are: Standard 1: Governance for Safety and Quality in Health Service Organisations Standard 2: Partnering with Consumers Standard 3: Preventing and Controlling Healthcare-Associated Infections Standard 4: Medication Safety Standard 5: Patient Identification and Procedure Matching Standard 6: Clinical Handover Standard 7: Blood and Blood Products Standard 8: Preventing and Managing Pressure Injuries Standard 9: Recognising and Responding to Clinical Deterioration in Acute Health Care, and Standard 10: Preventing Falls and Harm from Falls. 13

20 2 Our work The Commission has produced a suite of resources to support implementation of the NSQHS Standards. In November 2012, the Commission published ten Safety and Quality Improvement Guides, one for each NSQHS Standard. To support small health services, the Commission also developed a Guide for Small Hospitals. The guides were designed to help health service organisations align their quality improvement programs with the NSQHS Standards framework. They provide examples of strategies and resources that can be applied on a local scale. The Commission also developed a Hospital Accreditation Workbook and Day Procedure Services Accreditation Workbook to guide and support health service organisations through the accreditation process. To facilitate and enhance uptake of the NSQHS Standards, the Commission distributed 2,083 hard copies of the NSQHS Standards and 1,804 Safety and Quality Improvement Guides to health service organisations throughout Australia. Boxed sets including the NSQHS Standards, guides and other resources were distributed to every hospital and day procedure service in the country. States and territories have also reproduced and distributed copies of the NSQHS Standards. To achieve a shared understanding of the purpose of the NSQHS Standards, the Commission delivered presentations to health service organisations, jurisdictions, healthcare associations and industry groups. The Commission s representatives made presentations at over 50 meetings and conferences throughout 2012/13. The Commission s web site is also an important resource, providing healthcare providers with timely access to information, tools and resources. The NSQHS Standards and Accreditation homepage received more than 66,000 hits during 2012/13. The NSQHS Standards document was downloaded more than 16,000 times. Hospitals and day procedure services started the accreditation process on 1 January Over 1,340 public and private hospitals and day procedure services are required to be assessed by 2016, as determined by the schedule set by health service organisations. The Commission is beginning a program of work with researchers from the University of Newcastle to evaluate the impact of the NSQHS Standards on patient outcomes and patients perceptions of care. Key achievements 2012/13 2,083 copies of NSQHS Standards distributed 1,804 copies of Safety and Quality Improvement Guides distributed More than 16,000 downloads of the NSQHS Standards from the Commission s web site 14

21 Our work 2 Supporting implementation The Commission established the NSQHS Standards Accreditation Advice Centre in September 2012 to guide and support health service organisations, surveyors and accrediting agencies. As at 30 June 2013, the Advice Centre had received more than 1,240 requests for information. The most frequent queries related to individual standards and their requirements (most commonly NSQHS Standards 3, 5 and 9). Users also requested implementation resources, particularly high-resolution images of the NSQHS Standards icons for reproduction in service-specific documents and materials. The Advice Centre also coordinated network meetings to provide information to address local implementation issues. The Commission convened more than 30 online network meetings with approximately 500 healthcare representatives. The meetings were particularly useful in helping small healthcare services to better understand the NSQHS Standards. The Commission also provided a mediation service to resolve issues during the assessment process. Mediation involves an onsite meeting between the Commission, a health service organisation and a surveyor. As at 30 June 2013, mediation had been sought by eight health service organisations being surveyed. Implementation progress The Commission has introduced a number of flexible arrangements to help health service organisations achieve accreditation to the NSQHS Standards. These include giving health service organisations additional time to address any actions that were identified as needing attention during initial assessment; specifying minimum requirements for seven core actions during 2013; and reducing the number of requirements for health service organisations undertaking mid cycle assessment or periodic review in The Commission also identified developmental targets that health service organisations must show they are gradually adopting. As at 30 June 2013, 137 health service organisations had undergone an accreditation assessment. Of these: 49 health service organisations had an organisation-wide assessment against Standards 1 to health service organisations underwent a mid-cycle assessment against Standards 1 to 3 44 health service organisations achieved accreditation to the NSQHS Standards, and 93 health service organisations were given 120 days to make improvements needed to achieve accreditation. Key achievements 2012/ health service organisations assessed for accreditation from 1 January to 30 June health service organisations achieved accreditation and 93 were given additional time to finalise their accreditation 15

22 2 Our work AHSSQA Scheme The Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme builds on the strengths of current accreditation arrangements and provides national coordination of accreditation processes. The Commission coordinates the AHSSQA Scheme and provides support to state and territory health departments that regulate the AHSSQA Scheme. The Commission has worked collaboratively with jurisdictions, health service organisations and accrediting agencies to implement the AHSSQA Scheme. This has included support for states and territories as they align their policies, procedures and reporting systems to the NSQHS Standards. Queensland, South Australia, Tasmania, Western Australia and Victoria have released policy statements or frameworks that describe their jurisdiction s requirements and regulatory response. Other jurisdictions are developing similar directives. In 2012/13, the Commission approved 12 accrediting agencies to assess health service organisations for compliance with NSQHS Standards. The Commission held two workshops with accrediting agencies to discuss the intent of the NSQHS Standards and helped to train their surveyors. Accrediting agencies are required to provide regulators and the Commission with information on the outcome of assessments. The Commission is working with the Department of Health s Enterprise Data Warehouse team to build secure systems to collect, store and report on assessment data. The process of informing health services and establishing collection systems and tools is underway. While the Commission will collect data on 2013 accreditation assessments, the data warehouse reporting functions are not expected to be fully operational until the end of Effective systems support healthcare providers and improve patient experiences. The NSQHS Standards provide the focus and framework for improving the safety and quality of health care. Evaluating the impact of the NSQHS Standards The Department of Health is funding the Commission to research the impacts of the NSQHS Standards. This project began in the fourth quarter of the 2012/13 financial year. This research will examine: the impact of the NSQHS Standards on clinical incident reporting and management, and patient and carer perceptions of care in the context of the NSQHS Standards. The Commission will gather research data until The Commission will obtain advice from advisory groups, health service organisations and jurisdictions on the safety and quality impacts of the NSQHS Standards as they implement the AHSSQA Scheme. 16

23 Our work 2 Feedback from health service organisations on the NSQHS Standards: I would like to compliment the Commission on producing the safety and quality standards, in particular the medication safety standard. It was great for us as a pharmacy department (and an institution) to be able to articulate in a much more meaningful way the work that we do to improve medication safety for our patients. There were excellent resources to use and tips as to the types of evidence to use as examples. Well done! Pharmacist Consultant, Public Hospital Since the implementation of the NSQHS Standards, we have observed improved incident review systems. Incidents were always reviewed; however, the process was difficult to track. Audits are now more comprehensive. Documentation has also improved and healthcare providers are more involved in quality and risk. Safety and Quality Manager, Private Hospital Clinical Care Standards In September 2012, the Commission began developing the Clinical Care Standards program. The program aims to reduce unwarranted variation in health care, ensure appropriate clinical care is provided, improve patient experiences, and enable decision making to be shared between consumers and healthcare providers. A Clinical Care Standard is a set of quality statements that describe key components of clinical care a person should be offered for a specific clinical condition or defined part of a patient journey. Indicators, which enable health service organisations to support quality improvement at the local level, will accompany each of the quality statements. The Commission has established working groups comprising consumers, clinicians and other healthcare experts to develop the initial sets of Clinical Care Standards in the areas of acute coronary syndrome, stroke and antimicrobial stewardship. The Commission has also set up an advisory committee to provide direction on developing and implementing the Clinical Care Standards. The Commission will release the draft Clinical Care Standards for acute coronary syndrome, stroke and antimicrobial stewardship for public consultation at the end of This body of work will continue during 2013/14 and 2014/15 as the Commission continues to develop new Clinical Care Standards for priority areas. The Commission will work with consumer and healthcare provider groups to establish the first set of Clinical Care Standards, and will develop resources and tools to support their implementation. Clinical Care Standards will be able to be applied in all settings of care including the acute, primary care and community sectors. 17

24 2 Our work National standards for mental health services The Commission has undertaken a number of initiatives to support the implementation of national standards in mental healthcare settings. This work has included developing networks and links with other agencies. In collaboration with the Department of Health and Ageing, and the Safety and Quality Partnership Standing Committee (Mental Health and Drug and Alcohol Principal Committee), the Commission undertook a project to map the NSQHS Standards and National Standards for Mental Health Services (developed by the Mental Health Commission in 2011). The project identified areas of duplication and difference between the two sets of standards. This work provided the basis for a Consultation Draft Accreditation Workbook, which was developed to help mental health services implement and understand if they were meeting the requirements of both sets of standards. The Commission is revising the workbook based on feedback from users. The updated workbook will be released in 2013/14. In January 2013, the Commission commenced a scoping study with the National Mental Health Commission on implementation of the two sets of standards. The study aims to find out the current level of uptake of the two sets of standards in the public, private and community sectors. The study also aims to identify the enablers, barriers and challenges for implementation. The study will also identify any gaps in the standards frameworks with respect to safety and quality. The Commission conducted an online survey of mental health service providers and consumers in May 2013, attracting 425 respondents. The next phase of the study involves holding discussions with focus groups nationwide from July to September

25 Our work 2 National clinical quality registries Australia currently has limited capacity to measure and monitor the degree to which health care benefits the patient, and how closely the care provided aligns with evidence based practice. Developing standardised national registries of clinical quality is a cost-effective way to address this limitation. In November 2012, the National Health Information and Performance Principal Committee and the Commission s Board endorsed the Commission s proposed national arrangements for clinical quality registries. The proposed arrangements underpinned by technical, operational and accreditation models and a costed infrastructure plan will be presented to AHMAC during 2013/14. Clinical quality registries are clinical databases that routinely collect, analyse and report on patient-related information to help improve the quality and safety of health care. In particular, clinical quality registries provide specific information about: the appropriateness of health care (whether the care delivered to patients is based on the best available evidence), and the effectiveness of health care, measured by the degree to which the care benefits the patient. Clinical quality registries improve on current models that measure historical data using research, by reporting on the quality of health care in a timely manner. However, few registries achieve national coverage and most operate under research arrangements, with mixed buy-in from health system funders and operators. The Commission has been developing national arrangements for clinical quality registries based on national Operating Principles and Technical Standards. The registries will enhance national reporting on the appropriateness and effectiveness of health care. 19

26 2 Our work Supporting quality practice and clinical standards The Commission has undertaken a range of programs and initiatives during the 2012/13 financial year to support high-quality clinical practice. While the development of specific Clinical Care Standards (detailed on page 17) became a priority this year, the Commission has ongoing work for other clinical areas. These include: clinical communications consultation on clinical registers for high-risk implantable devices end-of-life care falls prevention healthcare associated infection health literacy medication safety, and open disclosure. Clinical communications Clinical communication problems are a major contributing factor in 70% of hospital sentinel events. 3 Effective clinical handovers between clinicians can reduce common errors and improve patient safety and care. The Commission s Clinical Communications program is applied in key areas known to influence quality and safety outcomes throughout the patient s journey and transitions in patient care, including supporting the implementation of NSQHS Standard 6: Clinical Handover. In 2012/13, the Commission commenced a new area of work focused on patient clinician communication. An analysis found that effective patient clinician communication is an important element in almost all of the NSQHS Standards. The Commission also commissioned a review of relevant research and policy literature to better understand communication between patients and clinicians. The review highlighted the importance of effective patient-clinician communication, and presented evidence for improvement strategies. The Commission will use the findings from the literature review and analysis to identify future priorities for implementing the NSQHS Standards with respect to patient clinician communications. Consultation on clinical registers for high-risk implantable devices Several events have highlighted the need for clinical information on adverse health outcomes associated with using high risk implantable medical devices. This information is not currently available for post-market evaluation or to efficiently notify potentially affected patients in the event of a problem with a particular device. In October 2012, the Department of Health and Ageing engaged the Commission to provide advice on technical, governance and funding options for implementing clinical registers, to support the Therapeutic Goods Administration s post-market surveillance and patient contact capabilities for specific high-risk implantable medical devices. 20

27 Our work 2 The report recommended that medical device information be incorporated into hospital patient administrative systems to improve the ability to identify and contact patients in the event of a safety concern about an implanted device. End-of-life care More than half the people who die in Australia each year do so in acute healthcare facilities where the quality and safety of the end-of-life care they receive can vary greatly. For a significant number of patients, clinical deterioration in acute healthcare facilities may not be preventable or reversible, but rather a part of the normal dying process. 4-5 Many of these patients are unlikely to benefit from invasive and burdensome therapies. Instead, they may require end of life care that addresses their emotional and psychosocial needs, and relieves the distressing symptoms that can occur during the natural dying process. 6-7 Safe and high-quality end-of-life care can prevent, or at least minimise, significant distress for patients, their families and carers. There are also significant cost implications for society if unwanted or inappropriate medical treatments are continued. Even with the considerable investment in palliative care services, guidelines, education programs, care pathways and advanced care planning programs, there are still gaps in the quality and safety of end-of-life care. In 2012/13, the Commission undertook scoping and preliminary consultation work to understand the complex issues and barriers affecting the delivery of safe and high-quality end-of-life care in acute healthcare facilities. A background paper was developed which outlined the current policy and clinical framework within the Australian acute care setting as interpreted by consumers, healthcare providers and policymakers. It provides a platform for discussing the Commission s future work to improve the safety and quality of end of life care. In June 2013, the Commission began working with consumers, healthcare providers and other experts to develop a national consensus statement about the standard of end-of-life care that patients, families and carers should expect in acute care settings. This high-level agreement on a consistent set of principles to guide the delivery of end-of-life care in acute facilities will be used to develop a framework for accountability, to ensure positive change at the point of care. Key achievement 2012/13 More than 40 focus groups and interviews on end-of-life care held Feedback from healthcare provider on end-of-life care: Bringing [end-of-life care] together under a national program has so many advantages. From a safety and quality point of view, it s the only way to go. Having a national framework gives us buy-in that we couldn t get any other way. ICU and General Medicine Consultant, Private Hospital 21

28 2 Our work Falls prevention Falls are a significant cause of harm to older people across Australia, and are responsible in some cases for unnecessary hospitalisation, increased healthcare costs and premature death. Preventing and reducing the harm from falls in older people are safety and quality priorities under NSQHS Standard 10: Preventing Falls and Harm from Falls. In 2012/13, the Commission evaluated the awareness, quality and use of its 2009 publication, Preventing Falls and Harm from Falls in Older People: Best Practice Guidelines for Australian Hospitals. The Centre of Research Excellence in Patient Safety at Monash University undertook the research and found: the guidelines would be more beneficial if they included more specific recommendations senior staff were more aware of the guidelines than front-line staff, and hospitals were particularly active in observing patients at risk of falling, but more work is needed to manage patients with delirium and confusion, and to review psychoactive medicine use. The Commission has formed a National Falls and Falls Injury Prevention Reference Group to advise it on national falls prevention priorities, and help health service organisations to implement NSQHS Standard 10. The group met for the first time in August Healthcare associated infection Preventing healthcare associated infection is a key safety and quality priority, recognised in NSQHS Standard 3: Preventing and Controlling Healthcare Associated Infections. The Commission aims to develop a national approach to reducing healthcare associated infection. It will do this by identifying and addressing systemic problems and gaps, and ensuring leaders and decision makers in the public and private healthcare sectors undertake comprehensive, nationally coordinated action. National Hand Hygiene Initiative The Commission contracts Hand Hygiene Australia (HHA) to implement the National Hand Hygiene Initiative (NHHI). During 2012/13, the NHHI continued to increase national awareness of hand hygiene, with more than 690 hospitals regularly submitting NHHI compliance data. Hand hygiene compliance rates continue to improve across all jurisdictions and the private sector. At a national level, the most recent data period (January to March 2013) demonstrated the highest compliance rate (76.9%) since the NHHI s commencement. The NHHI continues to be recognised nationally and internationally, with HHA team members presenting at leading national and international forums on infection control. 22

29 Our work 2 HHA, in partnership with the Royal Australasian College of Surgeons, developed an online education package for surgical trainees. Released in December 2012, more than 600 surgical trainees had passed the program as at 30 June Key achievements 2012/13 77% hand hygiene compliance nationally Over 690 hospitals regularly submit hand hygiene data 420,000 healthcare providers have completed online learning in hand hygiene since the start of the NHHI Reducing antimicrobial resistance Studies have shown that patients with antimicrobial resistant infections are at least twice as likely to die than patients infected with non-resistant organisms. A major reason for antimicrobial resistance is the unnecessary and inappropriate use of antibiotics. Organisms that are resistant to entire classes of antibiotics are emerging rapidly, causing growing concern around the world. The Commission worked with NPS MedicineWise, state and territory health department representatives and the private hospital sector, to develop consistent messaging and coordinate promotional opportunities. The theme of the week was Preserve the Miracle. The Commission developed resources to help health services highlight the problem of resistance and the importance of appropriate antibiotic use. This included a dedicated web page providing access to information, promotional materials, key contacts and links to learning resources. The Minister for Health joined members of the Commission and NPS MedicineWise in Brisbane to mark the event on 14 November Key achievements 2012/13 First Australian Antibiotic Awareness Week coordinated with participation from all jurisdictions and the community More than 850 Antibiotic Awareness Week posters and pocket cards downloaded by health service organisations One of the Commission s national priorities is reducing antimicrobial resistance. In 2012/13, the Commission was involved in the first Australian Antibiotic Awareness Week, from 12 to 18 November The event provided a significant opportunity to promote the appropriate use of antibiotics among healthcare providers and the community, through a nationally coordinated approach. 23

30 2 Our work Multi resistant gram-negative bacteria An emerging threat worldwide is gram negative bacteria, which have developed high levels of resistance to a wide range of antibiotics. Of particular concern are a group of organisms called carbapenem-resistant enterobacteriaceae (CRE). These bacteria have been a major cause of illness and death in a number of countries. There are early signs of their emergence and spread in Australia. In 2011/12, the Healthcare Associated Infection (HAI) Advisory Committee agreed that multi-resistant gram-negative bacteria represent a significant threat to Australia. The Commission established a taskforce to develop priorities and recommendations to address the problem of multi-resistant gram-negative organisms, including surveillance, identification and control strategies. The taskforce comprises representatives from the Commission, the Australasian Society for Infectious Diseases, the Australasian College for Infection Prevention and Control, the Australian Society for Antimicrobials, the Public Health Laboratory Network and the Australian Group on Antimicrobial Resistance. The taskforce also included participants from all states and the Northern Territory. During 2012/13, the taskforce developed Guideline recommendations for the control of multi-drug resistant gram negatives: Control of carbapenem-resistant enterobacteriaceae. The guideline was endorsed by all jurisdictions in April 2013 and was provided to all hospitals in Australia in August Standardised infection prevention and control signage During 2012, the Commission convened a working group to determine the feasibility of developing nationally agreed, standardised infection prevention and control signage. The working group has produced a set of consistent signs for use in healthcare settings nationwide, to ensure compliance with standard, transmission based precautions. The Commission released these signs for use by healthcare facilities in March The four sets of posters highlight droplet, airborne, contact and standard precautions. Health literacy Consumers are at the centre of the health system. The decisions they make and the actions they take are vital to ensuring that society achieves good health outcomes, and enjoys safe and high-quality health care. 8 The Commission has a strong focus on consumer-centred approaches to care across all areas of its work. It has identified health literacy as a key component of consumer-centred care, and as a priority for safe and high-quality health care through a number of national policies. These include the Australian Safety and Quality Framework for Health Care, the Australian Safety and Quality Goals for Health Care, and the NSQHS Standards. People with low levels of individual health literacy are between one and a half and three times more likely to experience an adverse outcome. 9 Addressing health literacy can also be seen as a way of protecting consumers from potential harm

31 Our work 2 Late in 2012, the Commission released the Health Literacy Stocktake Consultation Report, which provided an overview of health literacy activities and initiatives across Australia. The report noted that although there were many varied activities occurring across the country to address health literacy, there is little coordination at a national level and limited opportunities for others to benefit from this work. Early in 2013, the Commission developed the Consumers, the health system and health literacy: Taking action to improve safety and quality consultation paper. The paper outlines the landscape and context for health literacy in Australia, and is the first step towards developing a national approach to improving health literacy. The paper was informed by meetings held with the Health Literacy Expert Advisory Group. Public consultation commenced in June Feedback on the paper and the subject more generally will be used to inform the next phase of the project: developing a consensus statement on health literacy. The actions taken and decisions made by consumers are fundamental to the safety, quality and effectiveness of health care. Health literacy is concerned with the skills and abilities of individual consumers, and the demands placed on them by the health system, be it in hospital, general practice or other settings. Medication safety Australia has a system that generally provides consumers with safe medicines, delivered safely. However, as with all forms of health care, there is a risk of error, which can harm consumers. Because they are commonly used, medicines are associated with more errors and adverse events than any other aspect of care. The Commission works to improve the safety and quality of medicine use in Australia. In conjunction with national and local organisations and individuals, the Commission s medication safety work focuses on system issues through five main streams: standardisation to reduce the risk of medication errors and patient harm continuity of care to improve the quality of medicine information and communication reducing practice gaps to encourage evidence-based approaches ensuring the safety of electronic medication initiatives, and advocating for medication safety and quality. Medication safety is recognised as an accreditation requirement in NSQHS Standard 4: Medication Safety. 25